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Heart failure and cardiomyopathies
Functional, morphological and electrocardiographical abnormalities in patients with apical hypertrophic cardiomyopathy and apical aneurysm: correlation with cardiac MR Kenichiro Suwa,1 Hiroshi Satoh,1,2 Makoto Sano,1 Mamoru Nobuhara,1 Takeji Saitoh,1 Masao Saotome,1 Tsuyoshi Urushida,1 Hideki Katoh,1 Kei Tawarahara,1 Hayato Ohtani,1 Yasushi Wakabayashi,1 Hiroyuki Takase,1 Hajime Terada,1 Yasuo Takehara,3 Harumi Sakahara,3 Hideharu Hayashi1
To cite: Suwa K, Satoh H, Sano M, et al. Functional, morphological and electrocardiographical abnormalities in patients with apical hypertrophic cardiomyopathy and apical aneurysm: correlation with cardiac MR. Open Heart 2014;1:e000124. doi:10.1136/openhrt-2014000124
▸ Additional material is available. To view please visit the journal (http://dx.doi.org/ 10.1136/openhrt-2014000124). Received 17 March 2014 Revised 25 June 2014 Accepted 15 July 2014
For numbered affiliations see end of article. Correspondence to Dr Hiroshi Satoh; [email protected]
ABSTRACT Objective: The prognosis of apical hypertrophic cardiomyopathy (APH) has been benign, but apical myocardial injury has prognostic importance. We studied functional, morphological and electrocardiographical abnormalities in patients with APH and with apical aneurysm and sought to find parameters that relate to apical myocardial injury. Methods: Study design: a multicentre trans-sectional study. Patients: 45 patients with APH and 5 with apical aneurysm diagnosed with transthoracic echocardiography (TTE) in the database of Hamamatsu Circulation Forum. Measure: the apical contraction with cine-cardiac MR (CMR), the myocardial fibrotic scar with late gadolinium enhancement (LGE)-CMR, and QRS fragmentation (fQRS) defined when two ECGleads exhibited RSR’s patterns. Results: Cine-CMR revealed 27 patients with normal, 12 with hypokinetic and 11 with dyskinetic apical contraction. TTE misdiagnosed 11 (48%) patients with hypokinetic and dyskinetic contraction as those with normal contraction. Apical LGE was apparent in 10 (83%) and 11 (100%) patients with hypokinetic and dyskinetic contraction, whereas only in 11 patients (41%) with normal contraction ( p1.3.13 Apical aneurysm was defined as a discrete thin-walled dyskinetic or akinetic segment of the most distal portion of the LV chamber.4 5 Patients with uncontrollable hypertension and with severe valvular diseases were not registered to the database. Obstructive atherosclerotic coronary artery disease was excluded by the absence of significant coronary arterial narrowing (>50% stenosis) at coronary cine or computed tomographic angiography (n=14 for APH and n=4 for apical aneurysm), or in the remaining patients, by absent histories of chest pain, coronary risk factors and acute coronary syndrome. All patients underwent CMR within 1 month after diagnosis with TTE. Three patients with complete bundle branch blocks (BBBs) were then excluded from the study in consideration of modification of apical wall motion. Finally, this study consisted of 50 patients (45 patients with APH and 2
5 with apical aneurysm), and the database was analysed retrospectively. This study protocol was conducted in accordance with the Declaration of Helsinki. Protocol for CMR CMR was performed on 1.5 tesla (T) MR systems (Enshu Hospital: Excelart Vantage 1.5 T, Toshiba, Japan; Hamamatsu University Hospital: Signa Infinity Twinspeed, GE Medical Systems, Waukesha, USA; Hamamatsu Red Cross Hospital: Acheiva 1.5 T, Phillips Inc, Bothell, USA; Kosai General Hospital: Vantage Titan, Toshiba, Japan; and Seirei Mikatahara General Hospital: Signa Horizon Release 5.7, GE Medical Systems). The details of MR systems are described elsewhere.10 18 Typically, two-dimensional (2D) FIESTA and LGE images were acquired in the short axis, vertical long axis and horizontal long axis orientations. The slice thickness/gap was typically 10 mm/0 mm (6–9 slices). Breath-hold cine MRIs were obtained in contiguous short-axis planes from apex to base of the heart with the patient in a resting state. The 2D FIESTA cine images were based on the steady state free precession sequence. The imaging parameters were as follows: matrix of 192×192, field of view of 34 cm, flip angle of 45° and readout bandwidth of 125 kHz. Sixteen data lines were acquired per segment. LGE images were acquired 15 min after an injection of 0.2 mmol/kg of contrast material (Gd-DTPA-BMA, Fuji Pharma, Tokyo, Japan). LGE imaging was based on the inversion recovery prepared fast gradient echo (IR-FGRE) sequence. The imaging parameters were as follows: matrix of 256×160, field of view of 34 cm, flip angle of 20° and readout bandwidth of 31.25 kHz. The IR-FGRE technique was repeated during every R-to-R interval and the trigger delay was 300 ms. The readout data line was 160 each, where 24 data lines were acquired per segment. The optimum inversion time (200–240 ms) was measured right before the LGE imaging. Analyses of CMR Two experienced cardiovascular radiologists (KS and HS) interpreted all the CMRs without knowledge of clinical findings. LV end-diastolic volume (LVEDV), endsystolic volume (LVESV), left ventricular ejection fraction (LVEF) and LV mass (LVM) were acquired from the 2D FIESTA cine images in short axis view. The values for LV volume and mass were indexed by dividing them with body surface area (LVEDV index, LVESV index and LVM index). We classified patients into three groups according to apical contraction: (1) normal: apical hypertrophy and spade-like morphology at end-diastole and a disappearance of apical cavity at end-systole, (2) hypokinetic: apical hypertrophy and spade-like morphology at enddiastole with retention of apical cavity at end-systole and (3) dyskinetic: apical wall thinning and dyskinetic apical contraction (with or without ventricular obstruction;
Suwa K, Satoh H, Sano M, et al. Open Heart 2014;1:e000124. doi:10.1136/openhrt-2014-000124
Downloaded from http://openheart.bmj.com/ on January 11, 2016 - Published by group.bmj.com
Heart failure and cardiomyopathies
Figure 1 A representative patient with normal apical contraction. (A) Cine-cardiac MRIs (CMRs) at end-diastole (left) and end-systole (right). Apical hypertrophy and spade-like morphology at end-diastole and a complete disappearance of apical cavity at end-systole were shown. (B) Late gadolinium enhancement (LGE)-CMRs at short-axis view (left) and horizontal long-axis view (right). No LGE was observed. (C) Standard 12-lead ECG. High voltage QRS complexes, strain type ST depression and giant negative T waves were apparent.
figures 1–3). Regional analyses of LGE-CMR were performed using the 17-segment model.15 Then we examined the presence of LGE in each segment, determined the presence or absence of apical LGE and counted the number of segments with LGE. The apical injury was defined to be impaired apical contraction (hypokinetic or dyskinetic contraction) or the presence of apical LGE. The apical contraction and the presence, location and extent of LGE were determined by the consensus of the two observers with analyses of all the orientations. Analyses of 12-lead ECG and TTE Twelve-lead ECG and TTE were performed before CMR (
Heart failure and cardiomyopathies
Functional, morphological and electrocardiographical abnormalities in patients with apical hypertrophic cardiomyopathy and apical aneurysm: correlation with cardiac MR Kenichiro Suwa,1 Hiroshi Satoh,1,2 Makoto Sano,1 Mamoru Nobuhara,1 Takeji Saitoh,1 Masao Saotome,1 Tsuyoshi Urushida,1 Hideki Katoh,1 Kei Tawarahara,1 Hayato Ohtani,1 Yasushi Wakabayashi,1 Hiroyuki Takase,1 Hajime Terada,1 Yasuo Takehara,3 Harumi Sakahara,3 Hideharu Hayashi1
To cite: Suwa K, Satoh H, Sano M, et al. Functional, morphological and electrocardiographical abnormalities in patients with apical hypertrophic cardiomyopathy and apical aneurysm: correlation with cardiac MR. Open Heart 2014;1:e000124. doi:10.1136/openhrt-2014000124
▸ Additional material is available. To view please visit the journal (http://dx.doi.org/ 10.1136/openhrt-2014000124). Received 17 March 2014 Revised 25 June 2014 Accepted 15 July 2014
For numbered affiliations see end of article. Correspondence to Dr Hiroshi Satoh; [email protected]
ABSTRACT Objective: The prognosis of apical hypertrophic cardiomyopathy (APH) has been benign, but apical myocardial injury has prognostic importance. We studied functional, morphological and electrocardiographical abnormalities in patients with APH and with apical aneurysm and sought to find parameters that relate to apical myocardial injury. Methods: Study design: a multicentre trans-sectional study. Patients: 45 patients with APH and 5 with apical aneurysm diagnosed with transthoracic echocardiography (TTE) in the database of Hamamatsu Circulation Forum. Measure: the apical contraction with cine-cardiac MR (CMR), the myocardial fibrotic scar with late gadolinium enhancement (LGE)-CMR, and QRS fragmentation (fQRS) defined when two ECGleads exhibited RSR’s patterns. Results: Cine-CMR revealed 27 patients with normal, 12 with hypokinetic and 11 with dyskinetic apical contraction. TTE misdiagnosed 11 (48%) patients with hypokinetic and dyskinetic contraction as those with normal contraction. Apical LGE was apparent in 10 (83%) and 11 (100%) patients with hypokinetic and dyskinetic contraction, whereas only in 11 patients (41%) with normal contraction ( p1.3.13 Apical aneurysm was defined as a discrete thin-walled dyskinetic or akinetic segment of the most distal portion of the LV chamber.4 5 Patients with uncontrollable hypertension and with severe valvular diseases were not registered to the database. Obstructive atherosclerotic coronary artery disease was excluded by the absence of significant coronary arterial narrowing (>50% stenosis) at coronary cine or computed tomographic angiography (n=14 for APH and n=4 for apical aneurysm), or in the remaining patients, by absent histories of chest pain, coronary risk factors and acute coronary syndrome. All patients underwent CMR within 1 month after diagnosis with TTE. Three patients with complete bundle branch blocks (BBBs) were then excluded from the study in consideration of modification of apical wall motion. Finally, this study consisted of 50 patients (45 patients with APH and 2
5 with apical aneurysm), and the database was analysed retrospectively. This study protocol was conducted in accordance with the Declaration of Helsinki. Protocol for CMR CMR was performed on 1.5 tesla (T) MR systems (Enshu Hospital: Excelart Vantage 1.5 T, Toshiba, Japan; Hamamatsu University Hospital: Signa Infinity Twinspeed, GE Medical Systems, Waukesha, USA; Hamamatsu Red Cross Hospital: Acheiva 1.5 T, Phillips Inc, Bothell, USA; Kosai General Hospital: Vantage Titan, Toshiba, Japan; and Seirei Mikatahara General Hospital: Signa Horizon Release 5.7, GE Medical Systems). The details of MR systems are described elsewhere.10 18 Typically, two-dimensional (2D) FIESTA and LGE images were acquired in the short axis, vertical long axis and horizontal long axis orientations. The slice thickness/gap was typically 10 mm/0 mm (6–9 slices). Breath-hold cine MRIs were obtained in contiguous short-axis planes from apex to base of the heart with the patient in a resting state. The 2D FIESTA cine images were based on the steady state free precession sequence. The imaging parameters were as follows: matrix of 192×192, field of view of 34 cm, flip angle of 45° and readout bandwidth of 125 kHz. Sixteen data lines were acquired per segment. LGE images were acquired 15 min after an injection of 0.2 mmol/kg of contrast material (Gd-DTPA-BMA, Fuji Pharma, Tokyo, Japan). LGE imaging was based on the inversion recovery prepared fast gradient echo (IR-FGRE) sequence. The imaging parameters were as follows: matrix of 256×160, field of view of 34 cm, flip angle of 20° and readout bandwidth of 31.25 kHz. The IR-FGRE technique was repeated during every R-to-R interval and the trigger delay was 300 ms. The readout data line was 160 each, where 24 data lines were acquired per segment. The optimum inversion time (200–240 ms) was measured right before the LGE imaging. Analyses of CMR Two experienced cardiovascular radiologists (KS and HS) interpreted all the CMRs without knowledge of clinical findings. LV end-diastolic volume (LVEDV), endsystolic volume (LVESV), left ventricular ejection fraction (LVEF) and LV mass (LVM) were acquired from the 2D FIESTA cine images in short axis view. The values for LV volume and mass were indexed by dividing them with body surface area (LVEDV index, LVESV index and LVM index). We classified patients into three groups according to apical contraction: (1) normal: apical hypertrophy and spade-like morphology at end-diastole and a disappearance of apical cavity at end-systole, (2) hypokinetic: apical hypertrophy and spade-like morphology at enddiastole with retention of apical cavity at end-systole and (3) dyskinetic: apical wall thinning and dyskinetic apical contraction (with or without ventricular obstruction;
Suwa K, Satoh H, Sano M, et al. Open Heart 2014;1:e000124. doi:10.1136/openhrt-2014-000124
Downloaded from http://openheart.bmj.com/ on January 11, 2016 - Published by group.bmj.com
Heart failure and cardiomyopathies
Figure 1 A representative patient with normal apical contraction. (A) Cine-cardiac MRIs (CMRs) at end-diastole (left) and end-systole (right). Apical hypertrophy and spade-like morphology at end-diastole and a complete disappearance of apical cavity at end-systole were shown. (B) Late gadolinium enhancement (LGE)-CMRs at short-axis view (left) and horizontal long-axis view (right). No LGE was observed. (C) Standard 12-lead ECG. High voltage QRS complexes, strain type ST depression and giant negative T waves were apparent.
figures 1–3). Regional analyses of LGE-CMR were performed using the 17-segment model.15 Then we examined the presence of LGE in each segment, determined the presence or absence of apical LGE and counted the number of segments with LGE. The apical injury was defined to be impaired apical contraction (hypokinetic or dyskinetic contraction) or the presence of apical LGE. The apical contraction and the presence, location and extent of LGE were determined by the consensus of the two observers with analyses of all the orientations. Analyses of 12-lead ECG and TTE Twelve-lead ECG and TTE were performed before CMR (
